- Email: [email protected]
Using Focus Groups to Identify Factors Affecting Healthful Weight Maintenance in Latino Immigrants
Research Brief Using Focus Groups to Identify Factors Affecting Healthful Weight Maintenance in Latino Immigrants Mary L. Greaney, PhD1; Faith D. Lees, MS2; Breanna Lynch, MS, RD, CDE3; Linda Sebelia, MS, RD, LDN4; Geoffrey W. Greene, PhD, RD, LDN4 ABSTRACT Objective: To explore (1) how migration influenced physical activity and dietary behaviors among Latino immigrants and (2) participants’ perception of concepts related to a Health at Every Size (HAES) approach to weight maintenance (mindful eating, taking care of oneself). Methods: Four focus groups (n ¼ 35), homogenous by sex, were conducted in Spanish. Results: Male and female participants spoke of being less physically active and eating less healthful diets since immigrating. Noted barriers to being physically active and eating a healthful diet included time and financial constraints. Participants were interested in the HAES concepts but thought these ideas conflicted with their cultural upbringing. For women, putting family first was identified as a barrier to taking care of oneself. Conclusions and Implications: An HAES approach may be a useful in promoting weight maintenance in this population, as participants were interested in key concepts, but it would be important that HAES interventions incorporate cultural traditions. Key Words: Latino immigrants, weight management, focus groups (J Nutr Educ Behav. 2012;44:448-453.)
INTRODUCTION Overweight and obesity is a major public health concern in the United States (US).1,2 Latinos are at high risk of being overweight and obese: an estimated 37.9% of Latinos are obese and 76.9% are obese/overweight.3 The causes of obesity are multifactorial; physical inactivity and unhealthful dietary patterns are recognized as significant contributors to obesityrelated morbidity and mortality. Thus, obesity prevention guidelines include recommendations for these 2 modifiable behaviors.1,2,4-6 The immigrant population is the fastest growing segment of the US population. Currently, immigrants constitute 12.5% of the US population, and 53.1% of immigrants are from Latin America.7 Although the prevalence of obesity and overweight is lower in immigrants than among US-born adults,
1
there has been a dramatic increase in obesity and overweight prevalence among immigrants.8 Notably the length of US residency has been found to be associated with increased rates of overweight and obesity.8-10 The increased prevalence of obesity among immigrants may be associated with acculturation to US norms.11 Most intervention research has focused on promoting weight loss among overweight and obese individuals, and only a limited number have focused on preventing overweight and obesity among high-risk populations such as Latino immigrants. Interventions that include treatment components addressing diet, exercise, and behavioral change have been effective in promoting and maintaining weight loss.12,13 Unfortunately, many individuals who successfully lose weight regain it within 5 years post-treatment.14 This regaining of
Department of Nutrition, Harvard School of Public Health, Boston, MA Program in Gerontology, University of Rhode Island, Kingston, RI 3 Maine Medical Partners, Portland, ME 4 Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI Address for correspondence: Mary L. Greaney, PhD, Public Health Nutrition, Department of Nutrition, Harvard School of Public Health, Boston, MA 02115; Phone: (617) 582-7942; Fax: (617) 632-5690; E-mail: [email protected] Ó2012 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR doi:10.1016/j.jneb.2011.11.008 2
448
lost weight suggests that alternate approaches to promote and maintain healthful weight should be explored. A Health at Every Size (HAES) approach (also referred to as a nondiet approach) may provide a useful approach to obesity prevention. This approach directs the focus away from weight loss to enhancing selfregulation through avoidance of dieting, increasing awareness of hunger and satiety (defined as eating when hungry and stopping eating when full), and respecting one's own and others' body size.15 Outcomes are weight neutral, and weight loss, which may or may not occur, is not the goal.16 Interventions using an HAES approach promote healthful practices, including increasing physical activity and eating a healthful diet.17 Although results are mixed, some interventions developed using this approach have been effective in preventing weight gain.15,16 Recent immigrants to the US are ideal candidates for obesity prevention efforts, as obesity among immigrant groups increases with increasing time spent living in the US.8-10 There is a 4-fold greater risk of obesity among Latino immigrants who have lived in the US for 15 years or more.10,18 It is important to understand changes in diet and
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 physical activity associated with immigration, as less healthful diets and reduced physical activity may be associated with increased weight. Thus, the primary purpose of this study was to use focus groups to explore how migration to the US changed diet and physical activity among Latinos. A secondary purpose was to explore participants' perceptions of HAES-related concepts.
METHODS Participants were recruited from a wellestablished, nonprofit, communitybased organization located in Central Falls, Rhode Island that provides an array of services to assist the Latino and immigrant communities in the state. According to data from the 2000 census, Central Falls is 47.8% Hispanic/Latino, and 29% of the population lives below the poverty level.19 Study eligibility requirements included self-identifying as Latino, being between 18-45 years of age, having no known chronic disease such as diabetes or hypertension requiring dietary intervention, being willing to participate in a focus group, and providing informed consent. A researcher trained in qualitative methodology moderated the 4 focus groups, which were homogenous by sex (2 focus groups were with men and 2 with women). The moderator conducted the focus groups in Spanish using a semistructured interview guide with open-ended questions. Prior to this study, the interview guide was piloted in 2 focus groups conducted with Latina immigrants.20 Based on the results of these pilot focus groups, the discussion guide was refined and then used for this present study. The discussion guide was designed to explore: (1) changes in diet and physical activity since immigration; (2) barriers to a healthful diet and physical activity; and (3) participants' perceptions of HAES-related concepts (mindful eating, body size acceptance, and the idea of taking care of oneself/putting oneself first). The focus groups were conducted as exploratory work to be incorporated into a planned intervention to be designed for Latino immigrants to prevent weight gain using an HAES approach.
Greaney et al 449
Table. Demographic Characteristics of Focus Group Participants (n ¼ 35)
Age, y (mean [SD]) Time in United States, y (mean [SD]) Marital status (% [n]) Married Single Widowed/divorced Education (% [n]) High school diploma or less High school diploma or more Native country (% [n]) Puerto Rico/Dominican Republic Guatemala Columbia Argentina Mexico Bolivia Peru Living situation (% [n]) Live with others (nonrelatives) Live alone Live with children, parents, and/or relatives Annual income (% [n]) < $10,000 $10,000-$19,999 $20,000þ
Men (n ¼ 15) 35.1 (8.4) 5.5 (5.9)
Women (n ¼ 20) 35.2 (8.5) 2.6 (1.0)
53 (8) 40 (6) 7 (1)
55 (11) 25 (5) 20 (4)
67 (10) 33 (5)
55 (11) 45 (9)
20 (3) 53 (8) 13 (2) 13 (2) 0 (0) 0 (0) 0 (0)
5 (1) 20 (4) 45 (9) 10 (2) 10 (2) 5 (1) 5 (1)
60 (9) 20 (3) 20 (3)
25 (5) 10 (2) 65 (13)
80 (12) 13 (2) 7 (1)
50 (10) 35 (7) 15 (3)
Note: Because of rounding, percentages may not equal 100.
Before each focus group, the moderator explained focus group procedures and participants provided written informed consent. Each focus group lasted approximately 90 minutes and was audiotaped and transcribed in Spanish. Standard methods in qualitative research were applied,21 and transcripts were translated into English with all identifiers removed. The English transcripts were coded independently by 2 qualitative researchers. Disagreements in coding were discussed until consensus was reached. Then the codes were categorized and examined using thematic analysis to identify key concepts and themes.22 Themes were examined across the focus groups to see whether different or similar themes emerged in the focus groups with men compared to those with women. Themes were organized using an ecological model as the framework into intrapersonal, interpersonal, and environmental categories.23 All participants completed a selfadministered sociodemographic ques-
tionnaire that assessed education, marital status, country of origin, and length of time living in the US. Means with standard deviations and frequencies were calculated for these data using SPSS (version 19, IBM Corporation, Somers, NY, 2011). The study was approved by the Institutional Review Board for the Protection of Human Subjects at the University of Rhode Island. Participants received a $20 gift card for study participation.
RESULTS Participants In total, 35 people (20 women, 15 men) participated in the focus groups, and all participants were originally from South America, Central America, Mexico, or the Caribbean. The majority (97%) reported an annual household annual of less than $20,000, and 60% had not graduated from high school. Additional details about the sample can be found in the Table.
450 Greaney et al
Changes in Diet and Physical Activity since Coming to the US Overwhelmingly, participants felt that their diets were more healthful in their home countries. Before coming to the US, participants said they frequently ate fresh fruit, vegetables, and meats that were readily available. Since immigrating, participants stated they eat more processed food, fast food, and snack food than they ate in their countries of origin. As a man said, ‘‘I normally eat French fries here, but I never ate them in my country.’’ In addition, participants spoke of eating in excess because of the abundance of food and large serving sizes available in the US. In addition to changes in their diets, both male and female participants noted their eating behaviors have changed since immigrating. Participants spoke of schedules that allowed for eating at set times in their home counties, which did not necessarily happen in the US, as a female participant stated, ‘‘Back home, I ate breakfast, lunch, and dinner at a specific time each day. When I moved here, skipping meals became a daily habit.’’ Reasons for skipping meals and/or not eating at designated times were primarily related to work schedules and being tired from work. Participants also felt that they were less physically active since coming to the US, and that this decrease occurred because physical activity was not incorporated into their day-today lives. Participants said they used to bike and walk for transportation in their native countries, and they now relied on cars. They also reported that in their home countries, they had free time in which to be physically active, in part because they had to work less, and that physical activity was a social event that could be done with friends and family members.
Barriers to Consuming a Healthful Diet and Being Physically Active At the intrapersonal level, a lack of dietary knowledge and preferring unhealthful food were identified as barriers to a healthful diet for both men and women. At the environmental level, both male and female partic-
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 ipants spoke of the high cost associated with healthful food and the low cost associated with less healthful food as being a barrier to healthful eating. As a participant said, ‘‘We buy the cheapest food, which isn't always healthy.’’ For both men and women, a lack of time because of working was seen as making it difficult to eat a healthful diet. Male participants were much more likely than female participants to state that work influenced their dietary choices and eating patterns; as a male participant said, ‘‘Back home, we sat at the table to eat all meals; here, no time [is] given to eat.’’ Another male participant stated, ‘‘My job does not allow for too much time to eat—mostly fast food on the run.’’ Finally, the limited availability of fresh produce and meats was noted as a barrier. Participants spoke of relying on frozen food because of its availability and perceived lower costs. As previously mentioned, participants felt that their physical activity levels had declined since coming to the US. Identified intrapersonal-level barriers for both men and women included a lack of motivation to be physically active. In addition, women spoke of physical activity not being a priority and that their eating patterns made it hard to be active; as a woman explained, ‘‘. not eating all day, then eating 1 big plate.’’ Interpersonal-level barriers to physical activity were identified for women and not men. Female participants spoke of physical activity participation being curtailed owing to family responsibilities, including child care and cooking for the family. Women also mentioned that a lack of support makes it difficult, as they had no one to watch their children if they exercised. Physical activity barriers were identified at the environmental level for both men and women. These barriers included the need to work long hours and multiple jobs, financial constraints/expenses associated with physical activity, lack of neighborhood resources, and cold weather. A few male participants spoke of working physically demanding jobs, and that they were too tired from this work to do additional exercise and they did not believe it was needed.
Diet, Physical Activity, and Impact on Weight Participants felt that a lack of physical activity and unhealthful dietary habits, including food selection motivated by cost as well as preferences for unhealthful food, made it difficult to be at or maintain a healthful weight. Participants were aware that being overweight is associated with health risks (eg, increased risk of heart attacks, diabetes, and high blood pressure). Participants recognized the importance of physical activity and healthful eating, as a female participant said, ‘‘Nutrition and physical activity are very important for maintaining an overall healthy body.’’ A male participant elaborated on this idea, ‘‘It is not always practical, but you could have a better life if [you] eat healthfully and exercise.’’ Participants were interested in learning more about eating a healthful diet and becoming physically active, but they wanted to learn how to incorporate these behaviors into their busy lives and financial constraints.
Discussion about HAES-related Concepts Before asking participants about what they thought about mindful eating, the moderator provided an explanation of mindful eating. Overall, participants thought that this was a good idea and were interested in learning more, although they did not currently practice mindful eating, as evidenced by both male and female participants stating that they ate when they were not hungry and continued eating when full. Female participants were more likely than men to mention eating when full, and they spoke of finishing a child's unfinished meals. Both men and women thought that not eating all the food that they were served went against their cultural upbringing that encouraged eating all the food one is served and emphasized the importance of a ‘‘clean plate.’’ As a male participant said, ‘‘It is tradition to eat what is served to you.’’ Another male participant said, ‘‘Culturally, when parents or your wife serve you food, you have to eat what is served.’’ Similarly, a female participant said, ‘‘We are taught that
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 we need to eat everything that is served and should not get up until food is finished.’’ However, a few participants noted that it is okay to not finish all the food one is served, because doing so will result in overeating. Participants also noted that they often serve themselves large portions and then finish all the food they take. Participants were asked to discuss their thoughts on their current body shape and size. The female participants were divided as to how they viewed their bodies (‘‘I feel good about my body’’ vs ‘‘I feel fat’’), and most women noted gaining weight since coming to the US. Similarly, the male participants were divided about their body shape and size (‘‘I feel good about my body’’ vs ‘‘I would like to return to my weight before I moved here’’). Like many of the female participants, they stated they had gained weight since immigrating, and most noted that they should lose weight. Male participants felt body shape and body size were more important issues for women then men. As a man said, ‘‘This is usually more important for women; women are more vulnerable to the shapes of other women.’’ In addition, participants were asked what they thought about the idea of taking care of oneself/putting oneself first. Both men and women thought that it is important to take care of oneself but that it can be difficult to do so. For women, their cultural upbringing of putting family first (parents, husband, and children) was seen as being a barrier to taking care of oneself. As a woman said, ‘‘In our culture, women have to take care of the family, and if something goes wrong, the mother is always blamed for everything.’’ For men, working and trying to support their families was seen as making it hard to take care of oneself. Both men and women were interested in learning more about this idea and thought that education, including about time management, would be helpful. However, some participants, primarily women, felt that taking care of oneself first was culturally unacceptable.
DISCUSSION Latinos are the largest and most rapidly growing population group in the
US, and the process of acculturating to the US is associated with developing obesity.24 Thus, interventions are needed to prevent obesity, and as increased length of time in the US is associated with increased risk of obesity, intervention efforts are needed for more recent immigrants in an effort to promote weight maintenance. As with all interventions, cultural preferences and cultural values should be taken into account.25 Much of the existing qualitative research examining changes in diet or physical activity since immigration and/or barriers to these behaviors have focused on Latina immigrants.26-28 This is one of the few studies that of which the authors are aware that has used qualitative methods to explore these issues among Latino men.29 Participants' perceptions that immigration was associated with negative effects on diet and physical activity mirrors findings of other studies,27,29 as do many of the identified barriers.26,30,31 Work (hours worked, work schedules, multiple jobs) was identified as barrier to physical activity for both men and women, but it was more salient for men. Women spoke of work preventing physical activity, but they more often spoke of work taking time away from their families and family responsibilities. An important barrier to weight maintenance was the importance of eating all the food that one is served. Participants also spoke of serving themselves servings that are too large, and then eating all the food they took. These would be important issues to address in interventions designed to promote weight maintenance. Although there was little variation in identified themes by sex, this remains an important addition to the existing body of literature, as patterns of food intake and physical activity are developed within the family context.26,32 Thus, it is important to recognize that many similar barriers to being physically active and consuming a healthful diet were identified for men and women. This finding suggests that many intervention strategies and messages may be applicable to both Latina and Latino immigrants. This study is the first study of which the authors are aware that explores
Greaney et al 451 Latino immigrants' perceptions of HAES-related concepts. Participants were interested in learning more about mindful eating and taking care of oneself/putting oneself first; however, many participants identified cultural barriers to implementing these concepts. Notably, female participants thought it would be very difficult to make themselves a priority given the importance of their families, and others have found similar results.33,34 Within Latino communities, the family is an important unit for change and should be taken into account when designing interventions for this population.35 Among both male and female participants, there was a range of acceptance of body shape, and this finding indicates that interventions with Latino and Latina immigrants should encourage body size acceptance, as individuals with greater body size satisfaction have been found to be more likely to engage in regular physical activity than those who are less satisfied with their body size.36 However, Contento and colleagues found that among low-income Latinas (n ¼ 187), those with greater body dissatisfaction or who wanted to be thinner consumed more healthful diets than those who were satisfied with their size, and they hypothesize that this finding may indicate that these individual are employing healthful dietary behaviors to lose weight.37 Study limitations include a lack of information on participant's weight status and a limited number of focus groups with a modest sample size, which may limit generalizeability. A strength of this study is that the focus groups were homogenous by sex, which allowed for analyses to determine whether there were differences in identified themes by sex.
IMPLICATIONS FOR RESEARCH AND PRACTICE To the authors' knowledge, an HAES intervention has not been tested in Latino immigrant populations. Although this present study has limited generalizeability, using an HAES approach may be appropriate to promote weight maintenance among Latino/Latina immigrants. It would
452 Greaney et al be important that intervention messages recognize that changes in diet and physical activity derive from multilevel factors. Cultural influences on behavior also would need to be acknowledged. For example, the intervention would need to address the issue of portion size and eating everything that one is served. In addition, intervention messages could be framed in culturally appropriate terms, such as taking time to care for oneself is important to one's family.
ACKNOWLEDGMENTS The study was supported by funding from the Rhode Island Agricultural Experiment Station grant: RH00131. The authors would like to acknowledge and thank all individuals who participated in the focus groups.
REFERENCES 1. US Department of Health and Human Services. The Surgeon General’s Vision for a Healthy and Fit Nation. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2010. 2. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. 3. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-241. 4. US Department of Health and Human Services. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report 2010. Bethesda, MD: National Institute of Health, National Heart, Lung, and Blood Institute; 1998. 5. Cummings S, Parham ES, Strain GW. Position of the American Dietetic Association: weight management. J Am Diet Assoc. 2002;102:1145-1155. 6. US Department of Health and Human Services. The Practical Guide to Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Institute of Health, National Heart, Lung, and Blood Institute; 2000.
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 7. Grieco EM, Trevelyan EN. Place of Birth of the Foreign-Born Population: 2009. ACSBR/09-1. http://www. census.gov/prod/2010pubs/acsbr09-15. pdf. Published October 2010. Accessed March 20, 2012. 8. Singh GK, Siahpush M, Hiatt RA, Timsina LR. Dramatic increases in obesity and overweight prevalence and body mass index among ethnicimmigrant and social class groups in the United States, 1976-2008. J Community Health. 2011;36:94-110. 9. Singh GK, Siahpush M. Ethnic-immigrant differentials in health behaviors, morbidity, and cause-specific mortality in the United States: an analysis of two national data bases. Hum Biol. 2002;74: 83-109. 10. Goel MS, McCarthy EP, Phillips RS, Wee CC. Obesity among US immigrant subgroups by duration of residence. JAMA. 2004;292:2860-2867. 11. Gordon-Larsen P, Harris KM, Ward DS, Popkin BM. Acculturation and overweight-related behaviors among Hispanic immigrants to the US: the National Longitudinal Study of Adolescent Health. Soc Sci Med. 2003;57:2023-2034. 12. Wing RR. Behavioral Weight Control. New York, NY: Guilford Press; 2002. 13. Klem ML, Wing RR, McGuire MT, Seagle HM, Hill JO. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr. 1997;66: 239-246. 14. Jeffery RW, Drewnowski A, Epstein LH, et al. Long-term maintenance of weight loss: current status. Health Psychol. 2000;19(1 suppl):5-16. 15. Foster GD, McGuckin BG. Nondieting approaches: principles, practices, and evidence. In: Wadden TA, Stunkard AJ, eds. Handbook of Obesity Treatment. New York, NY: Guilford Press; 2002:604-609. 16. Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10:9. http://www. nutritionj.com/content/10/1/69. Accessed March 20, 2012. 17. Brown LB. Teaching the Health at Every Size paradigm benefits future fitness and health professionals. J Nutr Educ Behav. 2009;41:144-145. 18. Kaplan MS, Huguet N, Newsom JT, McFarland BH. The association between length of residence and obesity among Hispanic immigrants. Am J Prev Med. 2004;27:323-326.
19. US Census Bureau. Census 2000 Data for the State of Rhode Island. http:// censtats.census.gov/data/RI/1604414140. pdf. Updated October 6, 2011. Accessed March 20, 2012. 20. Greene GW, Sebelia L, Stone E. Evaluation of a culturally sensitive healthful eating and activity program for Latinas. Poster presented at: Society for Nutrition Education Annual Conference; July 19-23, 2008; Atlanta, GA. 21. Maxwell JA. Qualitative Research Design: An Interactive Approach. Thousand Oaks, CA: Sage Publications; 1996. 22. Miles MB, Huberman AM. Qualitative Data Analysis. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 23. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351-377. 24. Himmelgreen DA, Perez-Escamilla R, Martinez D, et al. The longer you stay, the bigger you get: length of time and language use in the US are associated with obesity in Puerto Rican women. Am J Phys Anthropol. 2004;125:90-96. 25. Contento IR. Nutrition Education: Linking Research, Theory, and Practice. 2nd ed. Sudbury, MA: Jones and Bartlett; 2011. 26. Lindsay AC, Sussner KM, Greaney ML, Peterson KE. Influence of social context on eating, physical activity, and sedentary behaviors of Latina mothers and their preschool-age children. Health Educ Behav. 2009;36:81-96. 27. Sussner KM, Lindsay AC, Greaney ML, Peterson KE. The influence of immigrant status and acculturation on the development of overweight in Latino families: a qualitative study. J Immigr Minor Health. 2008;10:497-505. 28. Gomel JN, Zamora A. English- and Spanish-speaking Latina mothers’ beliefs about food, health, and mothering. J Immigr Minor Health. 2007;9:359-367. 29. Yeh MC, Ickes SB, Lowenstein LM, et al. Understanding barriers and facilitators of fruit and vegetable consumption among a diverse multi-ethnic population in the USA. Health Promot Int. 2008;23:42-51. 30. Eyler AA, Matson-Koffman D, Vest JR, et al. Environmental, policy, and cultural factors related to physical activity in a diverse sample of women: The Women’s Cardiovascular Health Network Project—summary and discussion. Womens Health. 2002;36:123-134. 31. Kaiser BL, Baumann LC. Perspectives on healthy behaviors among low-
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 income Latino and non-Latino adults in two rural counties. Public Health Nurs. 2010;27:528-536. 32. Lindsay AC, Sussner KM, Kim J, Gortmaker SL. The role of parents in preventing childhood obesity. Future Child. 2006;16:169-186. 33. Evenson KR, Sarmiento OL, Macon ML, Tawney KW, Ammerman AS. Environmental, policy, and cultural factors related to physical activity among Latina
immigrants. Womens Health. 2002;36: 43-57. 34. Martinez SM, Arredondo EM, Perez G, Baquero B. Individual, social, and environmental barriers to and facilitators of physical activity among Latinas living in San Diego County: focus group results. Fam Community Health. 2009;32:22-33. 35. Crawford PB, Gosliner W, Anderson C, et al. Counseling Latina mothers of preschool children about weight issues:
Greaney et al 453 suggestions for a new framework. J Am Diet Assoc. 2004;104:387-394. 36. Kruger J, Lee CD, Ainsworth BE, Macera CA. Body size satisfaction and physical activity levels among men and women. Obesity (Silver Spring). 2008;16:1976-1979. 37. Contento IR, Basch C, Zybert P. Body image, weight, and food choices of Latina women and their young children. J Nutr Educ Behav. 2003;35:236-248.
INTRODUCTION Overweight and obesity is a major public health concern in the United States (US).1,2 Latinos are at high risk of being overweight and obese: an estimated 37.9% of Latinos are obese and 76.9% are obese/overweight.3 The causes of obesity are multifactorial; physical inactivity and unhealthful dietary patterns are recognized as significant contributors to obesityrelated morbidity and mortality. Thus, obesity prevention guidelines include recommendations for these 2 modifiable behaviors.1,2,4-6 The immigrant population is the fastest growing segment of the US population. Currently, immigrants constitute 12.5% of the US population, and 53.1% of immigrants are from Latin America.7 Although the prevalence of obesity and overweight is lower in immigrants than among US-born adults,
1
there has been a dramatic increase in obesity and overweight prevalence among immigrants.8 Notably the length of US residency has been found to be associated with increased rates of overweight and obesity.8-10 The increased prevalence of obesity among immigrants may be associated with acculturation to US norms.11 Most intervention research has focused on promoting weight loss among overweight and obese individuals, and only a limited number have focused on preventing overweight and obesity among high-risk populations such as Latino immigrants. Interventions that include treatment components addressing diet, exercise, and behavioral change have been effective in promoting and maintaining weight loss.12,13 Unfortunately, many individuals who successfully lose weight regain it within 5 years post-treatment.14 This regaining of
Department of Nutrition, Harvard School of Public Health, Boston, MA Program in Gerontology, University of Rhode Island, Kingston, RI 3 Maine Medical Partners, Portland, ME 4 Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI Address for correspondence: Mary L. Greaney, PhD, Public Health Nutrition, Department of Nutrition, Harvard School of Public Health, Boston, MA 02115; Phone: (617) 582-7942; Fax: (617) 632-5690; E-mail: [email protected] Ó2012 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR doi:10.1016/j.jneb.2011.11.008 2
448
lost weight suggests that alternate approaches to promote and maintain healthful weight should be explored. A Health at Every Size (HAES) approach (also referred to as a nondiet approach) may provide a useful approach to obesity prevention. This approach directs the focus away from weight loss to enhancing selfregulation through avoidance of dieting, increasing awareness of hunger and satiety (defined as eating when hungry and stopping eating when full), and respecting one's own and others' body size.15 Outcomes are weight neutral, and weight loss, which may or may not occur, is not the goal.16 Interventions using an HAES approach promote healthful practices, including increasing physical activity and eating a healthful diet.17 Although results are mixed, some interventions developed using this approach have been effective in preventing weight gain.15,16 Recent immigrants to the US are ideal candidates for obesity prevention efforts, as obesity among immigrant groups increases with increasing time spent living in the US.8-10 There is a 4-fold greater risk of obesity among Latino immigrants who have lived in the US for 15 years or more.10,18 It is important to understand changes in diet and
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 physical activity associated with immigration, as less healthful diets and reduced physical activity may be associated with increased weight. Thus, the primary purpose of this study was to use focus groups to explore how migration to the US changed diet and physical activity among Latinos. A secondary purpose was to explore participants' perceptions of HAES-related concepts.
METHODS Participants were recruited from a wellestablished, nonprofit, communitybased organization located in Central Falls, Rhode Island that provides an array of services to assist the Latino and immigrant communities in the state. According to data from the 2000 census, Central Falls is 47.8% Hispanic/Latino, and 29% of the population lives below the poverty level.19 Study eligibility requirements included self-identifying as Latino, being between 18-45 years of age, having no known chronic disease such as diabetes or hypertension requiring dietary intervention, being willing to participate in a focus group, and providing informed consent. A researcher trained in qualitative methodology moderated the 4 focus groups, which were homogenous by sex (2 focus groups were with men and 2 with women). The moderator conducted the focus groups in Spanish using a semistructured interview guide with open-ended questions. Prior to this study, the interview guide was piloted in 2 focus groups conducted with Latina immigrants.20 Based on the results of these pilot focus groups, the discussion guide was refined and then used for this present study. The discussion guide was designed to explore: (1) changes in diet and physical activity since immigration; (2) barriers to a healthful diet and physical activity; and (3) participants' perceptions of HAES-related concepts (mindful eating, body size acceptance, and the idea of taking care of oneself/putting oneself first). The focus groups were conducted as exploratory work to be incorporated into a planned intervention to be designed for Latino immigrants to prevent weight gain using an HAES approach.
Greaney et al 449
Table. Demographic Characteristics of Focus Group Participants (n ¼ 35)
Age, y (mean [SD]) Time in United States, y (mean [SD]) Marital status (% [n]) Married Single Widowed/divorced Education (% [n]) High school diploma or less High school diploma or more Native country (% [n]) Puerto Rico/Dominican Republic Guatemala Columbia Argentina Mexico Bolivia Peru Living situation (% [n]) Live with others (nonrelatives) Live alone Live with children, parents, and/or relatives Annual income (% [n]) < $10,000 $10,000-$19,999 $20,000þ
Men (n ¼ 15) 35.1 (8.4) 5.5 (5.9)
Women (n ¼ 20) 35.2 (8.5) 2.6 (1.0)
53 (8) 40 (6) 7 (1)
55 (11) 25 (5) 20 (4)
67 (10) 33 (5)
55 (11) 45 (9)
20 (3) 53 (8) 13 (2) 13 (2) 0 (0) 0 (0) 0 (0)
5 (1) 20 (4) 45 (9) 10 (2) 10 (2) 5 (1) 5 (1)
60 (9) 20 (3) 20 (3)
25 (5) 10 (2) 65 (13)
80 (12) 13 (2) 7 (1)
50 (10) 35 (7) 15 (3)
Note: Because of rounding, percentages may not equal 100.
Before each focus group, the moderator explained focus group procedures and participants provided written informed consent. Each focus group lasted approximately 90 minutes and was audiotaped and transcribed in Spanish. Standard methods in qualitative research were applied,21 and transcripts were translated into English with all identifiers removed. The English transcripts were coded independently by 2 qualitative researchers. Disagreements in coding were discussed until consensus was reached. Then the codes were categorized and examined using thematic analysis to identify key concepts and themes.22 Themes were examined across the focus groups to see whether different or similar themes emerged in the focus groups with men compared to those with women. Themes were organized using an ecological model as the framework into intrapersonal, interpersonal, and environmental categories.23 All participants completed a selfadministered sociodemographic ques-
tionnaire that assessed education, marital status, country of origin, and length of time living in the US. Means with standard deviations and frequencies were calculated for these data using SPSS (version 19, IBM Corporation, Somers, NY, 2011). The study was approved by the Institutional Review Board for the Protection of Human Subjects at the University of Rhode Island. Participants received a $20 gift card for study participation.
RESULTS Participants In total, 35 people (20 women, 15 men) participated in the focus groups, and all participants were originally from South America, Central America, Mexico, or the Caribbean. The majority (97%) reported an annual household annual of less than $20,000, and 60% had not graduated from high school. Additional details about the sample can be found in the Table.
450 Greaney et al
Changes in Diet and Physical Activity since Coming to the US Overwhelmingly, participants felt that their diets were more healthful in their home countries. Before coming to the US, participants said they frequently ate fresh fruit, vegetables, and meats that were readily available. Since immigrating, participants stated they eat more processed food, fast food, and snack food than they ate in their countries of origin. As a man said, ‘‘I normally eat French fries here, but I never ate them in my country.’’ In addition, participants spoke of eating in excess because of the abundance of food and large serving sizes available in the US. In addition to changes in their diets, both male and female participants noted their eating behaviors have changed since immigrating. Participants spoke of schedules that allowed for eating at set times in their home counties, which did not necessarily happen in the US, as a female participant stated, ‘‘Back home, I ate breakfast, lunch, and dinner at a specific time each day. When I moved here, skipping meals became a daily habit.’’ Reasons for skipping meals and/or not eating at designated times were primarily related to work schedules and being tired from work. Participants also felt that they were less physically active since coming to the US, and that this decrease occurred because physical activity was not incorporated into their day-today lives. Participants said they used to bike and walk for transportation in their native countries, and they now relied on cars. They also reported that in their home countries, they had free time in which to be physically active, in part because they had to work less, and that physical activity was a social event that could be done with friends and family members.
Barriers to Consuming a Healthful Diet and Being Physically Active At the intrapersonal level, a lack of dietary knowledge and preferring unhealthful food were identified as barriers to a healthful diet for both men and women. At the environmental level, both male and female partic-
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 ipants spoke of the high cost associated with healthful food and the low cost associated with less healthful food as being a barrier to healthful eating. As a participant said, ‘‘We buy the cheapest food, which isn't always healthy.’’ For both men and women, a lack of time because of working was seen as making it difficult to eat a healthful diet. Male participants were much more likely than female participants to state that work influenced their dietary choices and eating patterns; as a male participant said, ‘‘Back home, we sat at the table to eat all meals; here, no time [is] given to eat.’’ Another male participant stated, ‘‘My job does not allow for too much time to eat—mostly fast food on the run.’’ Finally, the limited availability of fresh produce and meats was noted as a barrier. Participants spoke of relying on frozen food because of its availability and perceived lower costs. As previously mentioned, participants felt that their physical activity levels had declined since coming to the US. Identified intrapersonal-level barriers for both men and women included a lack of motivation to be physically active. In addition, women spoke of physical activity not being a priority and that their eating patterns made it hard to be active; as a woman explained, ‘‘. not eating all day, then eating 1 big plate.’’ Interpersonal-level barriers to physical activity were identified for women and not men. Female participants spoke of physical activity participation being curtailed owing to family responsibilities, including child care and cooking for the family. Women also mentioned that a lack of support makes it difficult, as they had no one to watch their children if they exercised. Physical activity barriers were identified at the environmental level for both men and women. These barriers included the need to work long hours and multiple jobs, financial constraints/expenses associated with physical activity, lack of neighborhood resources, and cold weather. A few male participants spoke of working physically demanding jobs, and that they were too tired from this work to do additional exercise and they did not believe it was needed.
Diet, Physical Activity, and Impact on Weight Participants felt that a lack of physical activity and unhealthful dietary habits, including food selection motivated by cost as well as preferences for unhealthful food, made it difficult to be at or maintain a healthful weight. Participants were aware that being overweight is associated with health risks (eg, increased risk of heart attacks, diabetes, and high blood pressure). Participants recognized the importance of physical activity and healthful eating, as a female participant said, ‘‘Nutrition and physical activity are very important for maintaining an overall healthy body.’’ A male participant elaborated on this idea, ‘‘It is not always practical, but you could have a better life if [you] eat healthfully and exercise.’’ Participants were interested in learning more about eating a healthful diet and becoming physically active, but they wanted to learn how to incorporate these behaviors into their busy lives and financial constraints.
Discussion about HAES-related Concepts Before asking participants about what they thought about mindful eating, the moderator provided an explanation of mindful eating. Overall, participants thought that this was a good idea and were interested in learning more, although they did not currently practice mindful eating, as evidenced by both male and female participants stating that they ate when they were not hungry and continued eating when full. Female participants were more likely than men to mention eating when full, and they spoke of finishing a child's unfinished meals. Both men and women thought that not eating all the food that they were served went against their cultural upbringing that encouraged eating all the food one is served and emphasized the importance of a ‘‘clean plate.’’ As a male participant said, ‘‘It is tradition to eat what is served to you.’’ Another male participant said, ‘‘Culturally, when parents or your wife serve you food, you have to eat what is served.’’ Similarly, a female participant said, ‘‘We are taught that
Journal of Nutrition Education and Behavior Volume 44, Number 5, 2012 we need to eat everything that is served and should not get up until food is finished.’’ However, a few participants noted that it is okay to not finish all the food one is served, because doing so will result in overeating. Participants also noted that they often serve themselves large portions and then finish all the food they take. Participants were asked to discuss their thoughts on their current body shape and size. The female participants were divided as to how they viewed their bodies (‘‘I feel good about my body’’ vs ‘‘I feel fat’’), and most women noted gaining weight since coming to the US. Similarly, the male participants were divided about their body shape and size (‘‘I feel good about my body’’ vs ‘‘I would like to return to my weight before I moved here’’). Like many of the female participants, they stated they had gained weight since immigrating, and most noted that they should lose weight. Male participants felt body shape and body size were more important issues for women then men. As a man said, ‘‘This is usually more important for women; women are more vulnerable to the shapes of other women.’’ In addition, participants were asked what they thought about the idea of taking care of oneself/putting oneself first. Both men and women thought that it is important to take care of oneself but that it can be difficult to do so. For women, their cultural upbringing of putting family first (parents, husband, and children) was seen as being a barrier to taking care of oneself. As a woman said, ‘‘In our culture, women have to take care of the family, and if something goes wrong, the mother is always blamed for everything.’’ For men, working and trying to support their families was seen as making it hard to take care of oneself. Both men and women were interested in learning more about this idea and thought that education, including about time management, would be helpful. However, some participants, primarily women, felt that taking care of oneself first was culturally unacceptable.
DISCUSSION Latinos are the largest and most rapidly growing population group in the
US, and the process of acculturating to the US is associated with developing obesity.24 Thus, interventions are needed to prevent obesity, and as increased length of time in the US is associated with increased risk of obesity, intervention efforts are needed for more recent immigrants in an effort to promote weight maintenance. As with all interventions, cultural preferences and cultural values should be taken into account.25 Much of the existing qualitative research examining changes in diet or physical activity since immigration and/or barriers to these behaviors have focused on Latina immigrants.26-28 This is one of the few studies that of which the authors are aware that has used qualitative methods to explore these issues among Latino men.29 Participants' perceptions that immigration was associated with negative effects on diet and physical activity mirrors findings of other studies,27,29 as do many of the identified barriers.26,30,31 Work (hours worked, work schedules, multiple jobs) was identified as barrier to physical activity for both men and women, but it was more salient for men. Women spoke of work preventing physical activity, but they more often spoke of work taking time away from their families and family responsibilities. An important barrier to weight maintenance was the importance of eating all the food that one is served. Participants also spoke of serving themselves servings that are too large, and then eating all the food they took. These would be important issues to address in interventions designed to promote weight maintenance. Although there was little variation in identified themes by sex, this remains an important addition to the existing body of literature, as patterns of food intake and physical activity are developed within the family context.26,32 Thus, it is important to recognize that many similar barriers to being physically active and consuming a healthful diet were identified for men and women. This finding suggests that many intervention strategies and messages may be applicable to both Latina and Latino immigrants. This study is the first study of which the authors are aware that explores
Greaney et al 451 Latino immigrants' perceptions of HAES-related concepts. Participants were interested in learning more about mindful eating and taking care of oneself/putting oneself first; however, many participants identified cultural barriers to implementing these concepts. Notably, female participants thought it would be very difficult to make themselves a priority given the importance of their families, and others have found similar results.33,34 Within Latino communities, the family is an important unit for change and should be taken into account when designing interventions for this population.35 Among both male and female participants, there was a range of acceptance of body shape, and this finding indicates that interventions with Latino and Latina immigrants should encourage body size acceptance, as individuals with greater body size satisfaction have been found to be more likely to engage in regular physical activity than those who are less satisfied with their body size.36 However, Contento and colleagues found that among low-income Latinas (n ¼ 187), those with greater body dissatisfaction or who wanted to be thinner consumed more healthful diets than those who were satisfied with their size, and they hypothesize that this finding may indicate that these individual are employing healthful dietary behaviors to lose weight.37 Study limitations include a lack of information on participant's weight status and a limited number of focus groups with a modest sample size, which may limit generalizeability. A strength of this study is that the focus groups were homogenous by sex, which allowed for analyses to determine whether there were differences in identified themes by sex.
IMPLICATIONS FOR RESEARCH AND PRACTICE To the authors' knowledge, an HAES intervention has not been tested in Latino immigrant populations. Although this present study has limited generalizeability, using an HAES approach may be appropriate to promote weight maintenance among Latino/Latina immigrants. It would
452 Greaney et al be important that intervention messages recognize that changes in diet and physical activity derive from multilevel factors. Cultural influences on behavior also would need to be acknowledged. For example, the intervention would need to address the issue of portion size and eating everything that one is served. In addition, intervention messages could be framed in culturally appropriate terms, such as taking time to care for oneself is important to one's family.
ACKNOWLEDGMENTS The study was supported by funding from the Rhode Island Agricultural Experiment Station grant: RH00131. The authors would like to acknowledge and thank all individuals who participated in the focus groups.
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